Acute Neck Pain

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Clinical Assessment

Red Flags

• Trauma
• Constitutional: Fever, night sweats, weight loss, history of cancer, immunosuppression, pain elsewhere, illicit drug use
• Iatrogenic: Recent surgery, catheterisation, venipuncture, manipulation
• Awkward posture
• Exotic exposure or recent overseas travel
• Neurological: Symptoms/signs, vomiting
• Cardiovascular: Risk factors, anticoagulants
• Genitourinary/Reproductive: UTI, haematuria, retention, uterine, breast
• Endocrine: Corticosteroids, diabetes, hyperparathyroid
• Gastrointestinal: Dysphagia
• Integumentary: Infections, rashes
• Respiratory: Cough, haemoptysis

It is rarely possible to establish a patho-anatomic diagnosis in acute neck pain, and so the diagnostic process is one of exclusion.

The first step is evaluating whether the patient has neurological symptoms or signs. If they do then they should be assessed under a neurological disorders framework rather than an acute neck pain framework as the neurological disorder takes precedence. Neurological disorders include spinal cord injury, myelopathy, and radiculopathy.

In the event of trauma, the Canadian C-spine rule should be used, and any fracture managed as appropriate.

Diagnosis

For patients with no history of injury the diagnosis used by the Australian Acute Musculoskeletal Guidelines is "idiopathic neck pain," while for those with neck pain following a motor vehicle accident the diagnosis is "whiplash-associated neck pain." For ACC medicolegal purposes the coding that should be used is normally "cervical sprain," but this is not a meaningful label in a medical sense as it lacks legitimacy as a diagnosis.

Management

Passive Treatment

Passive treatment is avoided. It is not effective, especially when compared to other methods. Passive management assumes that a specific diagnosis has been made, and that passive treatment will rectify said diagnosis. However no conventional examination or investigation can identify the pathology and no conventional treatment can target or resolve any specific cause of pain

Explanation and Reassurance

These often go together. Elicit the patient's ideas and concerns. Gently correct false beliefs and address any fears about serious causes or about the prognosis. A clinical assessment can effectively rule out sinister causes and so the clinician can provide reassurance based on sound evidence. The patient many not have any specific concerns or fears. Regardless the clinician should fully reassure the patient that serious causes of neck pain are rare and can be recognised on clinical assessment, and common causes are not threatening and have a good prognosis. The clinician should be truthful that in the majority of cases no one knows what causes the pain, that it is probably something simple like a sprain or sore muscles, but that there is no simple way to make an exact diagnosis. Explain that even without treatment most patients recover, and that the most effective treatment is a tincture of time. However offer other measures as below to help the process along.

Activation

Encourage the patient to maintain activity as near to normal as possible. This is critical for preventing disability. Identify any barriers to achieving this, and be prepared to suggest alternative ways of maintaining activity levels if pain impedes this. Reassure the patient that there is no injury that will be worsened by resuming activity, and no injury that requires rest. Explain that rest can leads to stiffness and that the neck should be allowed to heal in a way that allows normal function. Resuming activities reminds the neck what is expected of it.

In some cases there will need to be goal setting in that the patient should start with a short time engaged in activity and gradually progress the length of engagement. Other interventions may be used to reduce pain to allow activation. There may need to be some discussions around ergonomics, although there is no particular rule. For example if the patient struggles to turn their head while driving encourage the use of mirrors. If hanging up the washing is problematic, then recommend that the patient hang the washing down by lowering the clothes line or standing on a stool.

Simple Exercises

Exercises for keeping the neck moving may be the single most effective measure for treatment of acute neck pain. They encourage resumption of normal activities, they have a therapeutic measure, and they are an active rather than passive modality. Patients are empowered to be the vehicles for their own recovery, and treatment can be applied when convenient. The patient should engage in the exercises at certain times of the day. Timing can be attached to other activities such as meal times, getting up in the morning, and going to bed at night. The objective is to increase and maintain mobility rather than strengthening the muscles or treating a specific lesion. Follow up can be offered to check compliance and understanding.

There are a couple of New Zealand publications that can be helpful

• McKenzie RA. Treat your own Neck. Spinal Publications, Waikanae, New Zealand, 1983.
• Mulligan B. Self treatments for back, neck and limbs. Plane View Services, Wellington, 2012.

Bibliography

• Bogduk, Nikolai, and Brian McGuirk. Management of acute and chronic neck pain : an evidence-based approach. Edinburgh New York: Elsevier, 2006.